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s FOR OFFICE USE: APPLICATION FORT SANITATION PERMIT <br /> Permit No. <br /> - -------------------------------------------------------- <br /> -•"-"- ----------- --- (Complete in Triplicate) <br /> --------- -------------- - p. 0r <br /> I f- This Permit Expires I Year From bate Issued' Date Issued - - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install fibs.work herein <br /> described. This application is made Kiri, compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . -� _ -.-- r- <br /> 9 - " -CENSUS TRACT <br /> Owner's Name - ----------P ne -------------------------------------- <br /> ----------------- <br /> --------------- - -- -.-• <br /> --- [ �7- ' l " ------- Cit <br /> ----------- ------------------------------------------ <br /> Address <br /> i License'#. `G ,� -- Phone =---------------' ---------- <br /> Contractor's Name --- ------ - ----------------�� ^ _ - 16t <br /> Installation will serve: ,Residence Apartment Hou e-❑,Commercial railer Court ;❑ <br /> Motel ❑ Other - . ---- "NZ <br /> ;5 <br /> Number of living units:_._ Number of bedrooms ___—_Garbage Grinder _.__________ Lot Size _______________________________�• <br /> Water Supply: Public System and name -------------------------------- ---------- Privdte <br /> Character ofsoil to a depth of 3 feet: Sand'❑ Silt❑ Clay., p_/Peat E] Sandy Loam*El <br /> 4 Clay foam [J . <br /> Hardpan ❑ Adobe ❑ Fill Mdterial ------.--.: If yes,type ---' Jt <br /> _,fPlot plan, showing size of lot, location of system in relation to we11s, buildings, •etc.' must-be placed on .reverse side.) <br /> NEW INSTALLATION: (No septic tank or <br /> seep a pit permitted if'public seyer is available within 200 feet,) <br /> Jam" id <br /> fDe�PACKAGE TREATMENT SEPTIC TANK'[ Li u > f= <br /> ` <br /> es a �=---------= <br /> { Capacity ------- ype - ------ -- - --- Mafierial W No. 'Compartments __ i <br /> + /Clistance to neares : Well --.-----`.-- Q---------:---.°_;Foundation'_--:=-�F�---------- Prop. Line ----�-�------•----- �,J <br /> LEACHING LINE`; [" �. No. of Lines ------�----------- Length of each' line,------ ----- ------------ Total Length '--- -------------------- <br /> X. <br /> ----------------- <br /> D'.. Box-f __ _ Type Filter Material __ -.��-_-___Depth Filter Material -----I_I-- °:---;' <br /> Distance' ne gest: Well `_ _Q__---,--- Foundatio ___ _ _�-- Property Line ---S-__�v <br /> F -_______ Diameter ------------ Rock Filled Yes <br /> Na <br /> —SEEPAGE PIT. [ Depth p _'� �-------------- <br /> Number -.----.-'-- -- / � <br /> Wats able Depth 0�_� -- ---------Rock Size ------- ---X-`------------ i f <br /> _ r r <br /> Distance.ao neares#::-Well- '------'1 0 -----------•------' Foundation---------- ------- Prop. Line ...--'=--------•----- <br /> 1 <br /> �r,REPAIR`/,ADDITION{Prey:Sanitation Permit# ------- -=-------------------------- - lute..-=:= --- -,--------------------1 <br /> .._ ----- <br /> Septic Tank (Specify Requirements) -------- ----- = ------------------------------ r '------- <br /> Disposal Field {Specify Requirements) ` = <br /> ------- <br /> _ <br /> ------- ----------I <br /> } <br /> . --------------------- <br /> ----------------------------------- <br /> (Draw --" <br /> ------------------- ---------------- ---- -- -i. existing and required addition on reverse side) <br /> I hereby certify that I: have prepared this application;and that the work will be done in accordance with San ,Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San .Joaquin Local Health District. Home owner or licen- <br /> sed agents signature a tifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Com ensation'laws of California." <br /> Signed -- - --- ----- ------ -------------------------- Owner <br /> i1 <br /> Title . ------------------------------------- <br /> ------------ <br /> BY - --- - <br /> - r {If ofiher than owner) <br /> FOR-DEPARTMENT USE ONLY <br /> APP LICATION"IACCEPTED BY -------- ----------------------------- ---- DATE Y ----------------- <br /> BUILDING PERMIT'ISSUED ------------------------ -------DATE ---------------- -------------------------- <br /> ADDITIONALCOMMENTS:'------- I-------------------------------------------------------------------------------------------- -----------------------------------------­_1----------- <br /> ----------------- ---- �`--- ----------------------------------------------------------------------------------- ----------------------------------------------- <br /> ---- <br /> ---------------------------- ----------- <br /> �. <br /> ---------------------- <br /> -----'------------------------------- -`"_." = - C �r <br /> Final Inspection bY: ------ •------ -----------------------------------------------------Date fes---- . ----- <br /> -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t <br /> E. 11. 9 1-'68 Rev. 5M <br />